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Issues in promoting health
PERGAMON
Social Science & Medicine 48 (1999) 711±718
Issues in promoting health David Mechanic * Institute for Health, Health Care Policy and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901, USA
Abstract Policymakers in many countries seek to contain health care costs over the long range by promoting health and more eective health behavior. Such eorts can be directed at entire populations, at members of a health plan, at de®ned risk groups or single individuals at risk. Many health risks are associated with socio-economic status and social inequalities but these are often dicult to address because of social and political con¯icts. Health, also, is often a product of culture and other social circumstances. Health may be promoted through non-health interventions or through more targeted health eorts seeking to eect behavior change. Preventive screening is of growing importance but such eorts often out-pace evidence of ecacy or cost-eectiveness. Many opportunities exist to build on new clinician±patient partnerships to make patients better informed and to eect positive health behavior. New technologies, and particularly the internet, oer new ways to promote health and more constructive illness behaviors. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Health promotion; Prevention; Social inequalities; Behavior change; Screening; Health status
1. Introduction This paper focuses on promoting health in memory of Sol Levine, a dear friend and close professional colleague for 35 years. This topic was chosen because his entire career was devoted in one way or another to understanding inequalities in health, factors eroding health status or interfering with eective provision of care and ways of enhancing health and the quality of life for all. In addition to being a formidable scholar, Sol had a special warmth and optimism that left a glow on all who came in contact with him. Our lives are less without him. Some biographical material can help put this presentation in context. In 1969 when I was Chair of the Medical Sociology Section of the American Sociological Association, I obtained a grant from the Carnegie Foundation for our section to explore various issues pertinent to impending national health insurance, which we all anticipated was around the
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corner. I became chair of its steering committee for the next six years and Sol was a close collaborator. As was his wont, he became chair of our implementation committee and a co-editor with me of one our products, ``Issues in Promoting Health'', a supplement to Medical Care (Mechanic and Levine, 1977). If one goes back and examines the content of our work on the grant, it would seem that little has changed over the subsequent two decades. We divided our work into two main areas: organizational consequences of national programs and preventive health and health maintenance. In respect to the ®rst, we believed that eective evaluation required better ways of measuring outcomes and we organized a program on sociomedical indicators under the leadership of Jack Elinson. The other two committees dealing with organizations tackled issues of professional organization and control and the eects of medical organization and technology on humane care. As we proceeded we also had a group addressing the role of psychosocial factors in medical utilization. In the prevention/health maintenance area, we had a productive eort under the leadership of the late Marshall Becker on the modi®cation of
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health behavior. We had a group working on barriers to medical care among Chicanos and another group working on a conceptual basis for family medicine. The entire eort was directed not only at publication and dissemination in the usual way but also to stimulate interaction and discussion among social scientists, health professionals and policy-makers. Implementation was in Sol's good hands and we got a lot of `bang for the buck'. Looking back, it is clear that we had picked many of the key issues crucial to our health futures and ones that continue to be core issues for research and social policy. Among our concerns, and especially important to Sol, was getting a better understanding of the role of nonhealth factors on health levels. Monroe Lerner ably chaired this group and produced a stimulating analysis of broad determinants of health (Lerner, 1977). Some years later when Alvin Tarlov, who became an intimate friend and colleague of Sol's, became President of the Henry J. Kaiser Foundation, health promotion and disease prevention became the Foundation's key focus. In 1987 they organized an invitational conference under the leadership of John Bunker on Pathways to Health: The Role of Social Factors (Bunker et al., 1989) and both Sol and I presented papers and played an active role. The mission of the Foundation was close to Sol's heart and being and he left his many friends and colleagues behind in Boston and moved to California as Vice-President of the Foundation where he administered review of the programs in health promotion, functional outcomes and South Africa. From early in his career, Sol looked to broad population approaches to promote health and improved health care. In the early years of his career this was a less common perspective, although now health authorities throughout the world look to broad population approaches to limit morbidity and disability and contain future health care expenditures. Ocial eorts to examine health broadly began with the Canadian LaLonde report in the 1970's (LaLonde, 1974), followed by the American Surgeon General's report on health promotion and disease prevention later in the decade (US Assistant Secretary of Health and Surgeon General, 1979) and somewhat later the development and monitoring of national health objectives (US Public Health Service, 1991). These eorts are now common in many other countries, for example, in England's health of the nation objectives (Secretaries of State for Health, 1992) and in 1997 the Blair government appointed England's ®rst minister of public health.
2. National health objectives In the United States the year 2000 objectives resulted from the work of 22 expert working groups, the involvement of the health departments of varying states, almost 300 national organizations and some ten thousand participants (US Public Health Service, 1995). Their eorts led to 22 major general objectives in such areas as physical activity and ®tness, nutrition, maternal and infant health, violent and abusive behavior, unintentional injuries and so on. Within each area objectives were directed at achieving a certain level of health outcome, reduction of health risks and those relating to services and protection. Setting realistic objectives is a signi®cant ®rst step. Implementing these in any reasonable way requires sophisticated strategies and clear understanding of social, environmental and behavioral factors that aect how individuals behave and how the social system functions. Many eorts today are directed at increasing empowerment of deprived individuals and communities and initiatives to involve them in cooperative groups that share information, provide support and facilitate active coping and eective political advocacy. Such group mobilization has signi®cant potential. However, in a challenging analysis seeking to identify fundamental causes of disease, Link and Phelan (1995, p. 89) suggest that ``The resources that accrue to the more advantaged allow them to regain the health advantage that may have been dented temporarily by the intervention''. They argue that unless change is directed at fundamental social causes that underlie socioeconomic dierences, those with higher socioeconomic status are likely in a short time to acquire the relevant information and resources that are health enhancing, increasing socioeconomic disparities in health. While there is substantial understanding of the extent to which broad environmental and societal factors aect health, particularly socio-economic status and associated living conditions (Bunker et al., 1989), most activities in prevention and health promotion are typically focussed on individuals and small groups. Individual behavior of course is only part of the variance, but addressing broader and perhaps more fundamental factors involve signi®cant political con¯ict and competing economic, religious and cultural values and interests. There are occasional opportunities for addressing socio-economic inequalities and disadvantage and other macro in¯uences (Benzeval et al., 1995) but more often than not health professionals have to focus on the available opportunities. The typical windows of opportunity are to promote behavior conducive to health and improved access to appropriate and eective health and social services. Opportunities are also generally available to strengthen communities, increase peoples' involvement and participation,
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strengthen social support networks and increase the sense of personal empowerment, all related in one way or another with more positive health behavior and improved health outcomes. The bulk of national investments is expended on medical care services with the challenge to provide a mix of services that meet critical needs in a cost eective way and that promote better health. No-one anymore believes, as the architects of the British National Health Service did, that providing access to medical care would signi®cantly improve health to the point that patient demand and medical expenditures decrease. For all practical purposes public demand for care will always exceed what nations are willing to ®nance and in allocating care all systems must ®nd some reasonable balance between goals and levels of service. Costs will continue to increase to whatever level societies are willing to allow. Using the available resources wisely depends on eective targeting. There is considerable evidence that the uninsured population, which has been growing in the United States, has much less access to care and poorer health outcomes than those who are insured (Weissman and Epstein, 1994) and that there are many missed opportunities for prevention by more rational allocation of services. An important way policymakers in developed countries hope to contain growing health costs over the longer range is to promote health and more eective health behavior (Mechanic and Rochefort, 1996). Such eorts can be directed at the entire population, at the members of a particular health care plan, at members of de®ned risk groups who are targeted for intervention, or even at single individuals at risk. 3. Health promotion and culture Healthful behavior is a byproduct of ordinary everyday activities (Mechanic, 1995). Health behaviors that require continuing motivation, planning and consideration of costs and bene®ts tend to be unstable and easily disrupted. In contrast, when the behavior results as a consequence of following routines of everyday living it is more deeply entrenched and occurs instinctively. Healthful behavior is best culturally ingrained and built-in to patterns of work, family life and recreation. The problem is that changing culture is a formidable task. Health promotion at the population level can be speci®cally health directed or a product of broader nonhealth interventions that are seen as good on their own terms. Fluoridation of the water supply or immunization of the population are health speci®c interventions. In contrast general education, or more speci®cally eorts to teach children decision-making skills, may have important eects on health but are
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seen as good on their own terms. For example, it is believed that children who successfully learn decisionmaking skills are more astute and cope better in resisting peer pressure to smoke, to use drugs, or to participate in other unwanted behaviors (Clabby and Elias, 1986; Institute of Medicine, 1994). The beauty of such indirect in¯uences is that interventions are without additional cost since they would be carried out for other reasons. Education, for example, is a very powerful health promoting in¯uence (Mechanic, 1989). Individuals who are better educated not only know more, but they are more active in seeking information, better able to evaluate it, retain more of it and are more likely to use it as a basis for decisions and behavior (Feldman, 1966). 4. Behavior change Mass media health education initiatives are often ineective. The message may be poorly constructed and ineectively communicated. It may be too imprecisely focussed to gain attention or to be persuasive. It may lack credibility among those who are most at risk or be targeted entirely at the wrong groups. Some years ago I was a consultant to an eort of major foundations to design a health education series for public television that was to use entertainment programming (Maibach and Holtgrave, 1995) to get a health message across. Unfortunately, it was de®ned by the public as a health program and very few people watched it despite a large investment in trying to make the material audience-friendly and entertaining. People are often suspicious of direct eorts to change their behavior and may be more in¯uenced by information that comes incidently than through obvious in¯uence attempts. The credibility of such information is less likely to be challenged. By building such communications into ordinary programming, cost is very much reduced. A project at the Harvard School of Public Health has worked with television representatives to use designated drivers in drinking situations in entertainment programming (Montgomery, 1990). This is an indirect way to get an idea across to the general public and legitimize it at low cost. The project has been successful in having the idea adopted but its health impact is unknown. The larger issue, of course, is the extraordinary amount of negative health programming found in the media encouraging drinking, fast driving, smoking, risk-taking and violence. The cost-eectiveness of health promotion interventions are enhanced by targeting subgroups at high risk who are most likely to bene®t from intervention. Examples include AIDS education with IV drug users (Miller et al., 1990) or interventions with youngsters during the period of greatest vulnerability to initiating
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smoking (Evans, 1985). This can be undertaken within health plans or more generally in the community at large. The sponsorship of the intervention, of course, will determine whether it is solely directed to health insurance plan enrollees or a more diverse population. An increasingly common intervention involves the mobilization of varying types of support groups, selfhelp groups, survivor groups and the like. There is a great variety of groups taking on many functions. They vary from such well known approaches as Alcoholics Anonymous (AA) to psychoeducational groups for families of patients with chronic diseases. Such groups often provide social support, information, coping skills and an improved sense of mastery. Interacting with other people with comparable or even greater problems than one's own can reduce the sense of isolation, increase one's sense of community and support a variety of useful coping approaches. A recent randomized controlled study of a psychoeducational program for families of persons with schizophrenia found that the same intervention was more successful when administered in a group as compared with an individual setting (McFarlane et al., 1995). While group interventions may not always be ideal, the group process often provides support and reinforcement beyond the content of the intervention. The evidence for the impact of social support on health and coping is impressive but not all social support eorts are necessarily eective and some, however well intentioned, could be harmful (Thoits, 1995). A great deal depends on the structure of the group and group processes, the goals and content of group activity and how the individual relates to the group. Groups can scapegoat and intimidate as well as support, can reinforce dysfunctional behaviors and can isolate individuals from other constructive and normalizing in¯uences. For example, self-help groups called `Double-Trouble' groups are being organized around a 12-step program for individuals with co-morbid substance abuse and mental illness. Such persons when they join more traditional 12-step programs like Alcoholics Anonymous are discouraged from using medications, but such persons often decompensate with medication noncompliance. Double-trouble groups, in contrast, are intended to develop a dierent culture around medication issues. In recent years selfhelp groups organized around speci®c areas such as breast cancer, AIDS, mental illness and disability have become in¯uential in public policy as well as providing education and social support to their participants (Rodwin, 1994).
5. Preventive screening Another approach to health promotion are initiatives for early recognition of risk and disease prevention. A focus on prevention super®cially is an attractive answer. The common assumption is that prevention eorts must be cost-saving since preventing illness in the ®rst place avoids all the costs. This is often true at the individual level but commonly untrue in the aggregate, a point that even some sophisticated health professionals have diculty comprehending. In fact, only a few preventive eorts have been demonstrated to be cost-saving, although they may be cost-eective or clearly justi®able on other grounds (Russell, 1986). The potential to reduce expenditures through preventive eorts will depend on the prevalence of the illness, the costs and eectiveness of preventive interventions, the frequency with which the intervention has to be repeated or reinforced, the size of the population that can potentially bene®t, the capacity to target persons at highest risk and many other factors (Russell, 1986). The principle of large numbers is important here in that even a modestly priced intervention directed at a large population, most of whom are unlikely to develop a disorder, may be inordinately expensive in the aggregate or in terms of the cost for each disorder prevented. Preventive screening is an area of great public interest but one which often has uncertain value (Russell, 1994). The scienti®c potential for new screening tests for dierent types of cancer, genetic defects and other diseases is large, but too aggressive marketing of such technologies could be cost-ineective and even dangerous. One need look no further than the widespread use of the PSA test for screening for prostate cancer to see the potential dangers. While prostate speci®c antigen (PSA) screening is reasonably eective in detecting prostate cancers, the test yields a high rate of false positives (Mandelson et al., 1995). Large numbers of men with high PSA values then begin a trajectory of diagnostic procedures of increasing invasiveness. However, even detecting cancers is of uncertain value since many of these tumors would not progress within the lifespan of the individual and there is no evidence that intervention reduces mortality (Russell, 1994; Mandelson et al., 1995). Moreover, the interventions have many serious risks and adverse consequences. The PSA test is an impressive innovation and provides useful information and some argue that information is valuable even if interventions are not undertaken. What is typically not recognized is how awareness that one might have cancer threatens individuals and how the information itself, often supported by an aggressive urological surgeon, pushes people onto a trajectory of uncertain interventions. While the potential for repeated expenditures on PSA tests and
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other followup diagnostic procedures and interventions are very large, bene®ts are uncertain. PSA is clearly a promising screening approach that merits investigation on how it might best be used, but it has already become relatively routine. The story of PSA can be multiplied manyfold with other diagnostic procedures and interventions that have been widely applied before their value has been ascertained (Russell, 1994). As Black and Welch (1993) note in relation to new imaging technologies, ``...many patients may have been labeled with disease they do not really have and many have been given therapy they do not really need''. The future will bring seemingly amazing new preventive screening technologies well before we have the evaluations that allow us to assess their worth. We may be in the position of having these technologies diffuse almost universally, such as electronic fetal heart rate monitoring, only to discover later that the new technology not only provided no advantage but also involved increased risk (Shy et al., 1990). The growth of managed care should inhibit these tendencies to some degree, but changes are also needed in the culture of medicine and the expectations of patients. An unquali®ed faith in the value of technology makes it dicult to introduce a balanced perspective. 6. Developing a new clinician±patient partnership One component of creating a new medical culture is to involve patients more actively in decisions about their treatments (Mechanic, 1998). Wennberg and his colleagues, for example, have developed impressive videotape materials for helping patients make intervention choices in such conditions as breast cancer and benign hypertrophy of the prostate (BHP). In these programs patients watch videotapes of thoughtful patients who faced a similar choice explain their reasoning in the selections they made. When presented with such options patients commonly prefer more conservative options than doctors (Wennberg, 1990). While such programs have great promise, they also present diculties. Patients are often excessively fearful of invasive interventions and are easily dissuaded from them. At times, something more than a neutral medical opinion is needed to overcome resistance to treatments that can be of signi®cant bene®t. Patients' preferences, of course, should determine the risks taken, but decision-making programs must be exceedingly careful in how they present options and choices. A related problem is the dynamic character of medical understanding and biomedical research. For example, the Wennberg materials on BHP are impressively done and both the presentations for the `watchful waiting' option and for surgery are persuasively and fairly presented. Maintaining a balanced objective view
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in the development of such materials, however, is exceedingly dicult, time-consuming and costly. Soon after the Wennberg videotapes became available the ®rst randomized controlled trial ever done, comparing surgery to watchful waiting among men with moderate symptoms, was reported in the New England Journal of Medicine (Wasson et al., 1995). The study found signi®cant symptom relief in the surgical group compared with watchful waiting and no greater serious adverse eects than in the watchful waiting group. This study suggests the possibility that some of the adverse eects typically attributed to surgery in clinical studies, such as impotence and incontinence, may be associated with the condition in some way and not with surgical intervention. A larger number of cases will be required to assess such issues de®nitively, but, in any case, these new results change the decision calculus. Developing tapes for important treatment decisions and keeping them up-to-date is a major enterprise. Since various groups have a ®nancial interest in treatment decisions, they often have dierent perspectives on the decision. Thus, treatment tapes might be produced by medical industries, drug companies, specialty organizations, etc. Some system is needed to review such treatment aids and accredit them if the public is not to become confused and misled. Moreover, once produced, there has to be an eective distribution system for these resources. In short, carrying forward on such innovations require careful eorts and considerable ®nancial resources. The ready availability of computers and improved interactive computer software oer many opportunities for health plans to help patients assess health risks, promote health in various areas and teach self-management skills relevant to various problems and diseases. Such instructional programs are also used in preparing patients for various procedures or in postsurgical instruction. Computers cannot ever fully replace interpersonal communication or opportunities to give information and receive speci®c feedback on the patient's unique experiences. Patients prefer interpersonal contact and are generally more in¯uenced by it than impersonal forms of communication. Good computer software, however, can help clinicians gather systematic information from patients and provide much general information to patients. Some of the time saved could be invested in personal followup to insure that patients' concerns have been addressed and to provide necessary feedback and reassurance. One innovative use of such technology and the internet is the Comprehensive Health Enhancement Support System (CHESS) developed by the Center for Health Systems Research and Analysis at the University of Wisconsin-Madison (Gustafson et al., 1993, 1994). This educational and supportive program now has modules for patients with AIDS, breast can-
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cer and other serious health programs as well as modules for family members of patients with Alzheimer's disease and alcoholism. A personal computer is placed in the home and the program oers eleven services including answers to frequently asked questions, articles and other informational resources, electronic access to relevant discussion and support groups, opportunities to ask questions to an expert via e-mail, decision aids, personal accounts of others with similar problems, etc. A major issue with any such program is the quality of the programming, its scienti®c credibility and its ®delity to the existing state of knowledge. CHESS and related approaches are still in a very early stage of development and there is much yet to be worked out. However, CHESS has been studied in randomized trials and has been shown to have high acceptability and use, to be accessible to persons with little education and minority status and to improve patients' participation in treatment and quality of life (Thorson, 1994; Peressin, 1995; Pingree et al., 1996; Center for Health Systems Research and Analysis, 1997). CHESS illustrates the enormous potential for using carefully screened information and decision aids and access to support groups as a way of contributing signi®cantly to a more involved and better informed patient.
7. Taking account of arational aspects of care Much of the eort to educate the public and change public and patient behavior is based on an implicit assumption of behavioral rationality. This isn't a bad assumption because people are substantially rational but it is important to be aware of the limitations of this viewpoint. Consider the extremely robust and persistent assumption that if incentives are provided to make people aware of the costs of their medical care, they will use care more judiciously and will primarily use care when it is appropriate and eective. Yet investigators repeatedly ®nd that ®nancial barriers to care reduce utilization but in an unselective fashion. Ecacious care is reduced as much as trivial services. For example, the RAND Health Insurance Experiment found that coinsurance was an eective barrier to utilization, but there was little dierentiation in its eects between useful and inappropriate care (Newhouse and the Insurance Experiment Group, 1993). Public health workers also have long known that providing health services free and making them accessible doesn't necessarily lead to their use in all populations. There is now a rich literature on illness behavior that examines the illness schemas people use and how they make sense of their internal experiences (McHugh and Vallis, 1986; Benyamini and Leventhal, 1997).
What may seem rational to an outside observer may have little relevance within the context of the individual's meaning systems and explanatory schemes. Any serious examination of utilization must be sensitive to the latent functions of medical care where people visit doctors to gain reassurance, to legitimate release from usual responsibilities, to account for failures to meet family and work obligations, to gain access to certain privileges or achieve other types of secondary gain (Mechanic, 1978). Much help-seeking is security based, but such concerns are typically neglected in making sense of utilization. Often the policy debate becomes very distant from reality. For example, some managed care organizations refuse to pay for emergency care visits if after the fact the problem turns out not to have been an emergency. However, the whole point of seeking emergency care in many instances is to obtain an informed assessment of symptoms that are frightening and worrisome. Even if the compromise that symptoms are an emergency if a `reasonable person' would have believed them to be so fails to take account of the large variations in people's fears and anxieties, cultural orientations, knowledge and understanding and coping capacities under stress.
8. The preventive potential of therapeutic relationships The clinician±patient relationship remains a source of signi®cant in¯uence and opportunity to promote improved health (Mechanic, 1998). Even short inquiries and discussions with patients about smoking can result in an increased cessation rate of about 5% (Russell et al., 1987). This may seem unimpressive, but it is one of the most eective uses of clinician time given the destructive consequences of smoking. It isn't that patients aren't aware that smoking is injurious to health, but the credibility and in¯uence of one's own physician and the discussion in the context of one's own health, can have a powerful impact. The clinical situation can also be a powerful context for teaching patients selfcare and self reliance. For example, one health plan instructed mothers on how to take throat cultures when their children had sore throats. The culture materials were given to the mothers and they could drop o the cultures at the clinic at their convenience rather than schedule a doctor or nurse appointment. Mothers liked this arrangement and an evaluation showed that they carried out the procedure in a satisfactory way (Katz and Clancy, 1974). Health programs are increasingly teaching patients to monitor their blood pressure, blood sugar and other health signs and increasingly sophisticated technologies make this easier.
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9. Conclusions In summary, there are many levels of promoting health, preventing disease and minimizing disability. In recent years there has been a resurgence of interest in the role of social inequalities in health outcomes and the role of socioeconomic variables. Studies increasingly report that inequalities net of economic status are associated with poor health (Kawachi and Kennedy, 1997) and at the individual level the importance of social support networks and sense of control is persistently demonstrated (Marmot et al., 1995). Sol Levine was particularly intrigued by these relationships and the possibilities they implied and was instrumental in setting up the Joint Program in Society and Health between the Harvard School of Public Health and the New England Medical Center and in encouraging young investigators who are now making major contributions to this ®eld. We still have much to learn about the complex interdependencies among these predictors but work is going forward at a more rapid pace because of Sol's eorts and encouragement (Amick et al., 1995). There are, of course, increasing opportunities in primary prevention through improved health understanding and increased healthful behavior, some preventive screening approaches that bring high bene®ts relative to cost and more sensitive and sophisticated use of clinician±patient relationships as tools to achieve greater health understanding and better health status. The struggle to prevent disease and improve health is a continuing one because health exists in the cultural context of people's values and aspirations and these are always changing in adapting to new environments. Eective public health and medicine, however, can make it more possible for all of us to ful®ll our goals and to achieve a high level of function and quality of life.
Acknowledgements Supported, in part, by a Robert Wood Johnson Foundation Health Policy Investigator Award.
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Russell, L.B., 1994. Educated Guesses: Making Policy about Medical Screening Tests. University of California Press, Berkeley. Russell, M.A.H., Stapleton, J.A., Jackson, P.H., Hajek, P., Belcher, M., 1987. District programme to reduce smoking: eect of clinic supported brief intervention by general practitioners. British Medical Journal 295, 1240±1244. Secretaries of State for Health, 1992. The Health of the Nation: a Strategy for Health for England. HMSO, Cmnd., London. Shy, K.K. et al, 1990. Eects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation on the neurologic development of premature infants. New England Journal of Medicine 322, 588±593. Thoits, P.A., 1995. Stress, coping and social support processes: where are we? What next?. Journal of Health and Social Behavior 36 (Extra issue), 53±79. Thorson, B., 1994. CHESS: an interactive computer system for women with breast cancer piloted with an under-served population. Journal of the American Informatics Association, Symposium Supplement, SCAMC Proceedings, pp. 599±603. US Assistant Secretary of Health and Surgeon General, 1979. Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention. DHEW Pub. No. (PHS) 79-55071. US Government Printing Oce, Washington, DC. US Public Health Service, 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Pub. No. (PHS) 91-50212. Government Printing Oce, Washington, DC. US Public Health Service, 1995. Healthy People: 2000 Review 1994. DHHS Pub. No. (PHS) 95-1256-1. National Center for Health Statistics, Hyattsville, Maryland. Wasson, J.H., Reda, D.J., Bruskewitz, R.C., Elinson, J., Keller, A.M., Henderson, W.G., 1995. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. New England Journal of Medicine 332, 75±79. Weissman, J.S., Epstein, A.M., 1994. Falling Through the Safety Net: Insurance Status and Access to Health Care. Johns Hopkins University Press, Baltimore. Wennberg, J.E., 1990. Outcomes research, cost containment, and the fear of health care rationing. New England Journal of Medicine 323, 1202±1204.
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Issues in promoting health David Mechanic * Institute for Health, Health Care Policy and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901, USA
Abstract Policymakers in many countries seek to contain health care costs over the long range by promoting health and more eective health behavior. Such eorts can be directed at entire populations, at members of a health plan, at de®ned risk groups or single individuals at risk. Many health risks are associated with socio-economic status and social inequalities but these are often dicult to address because of social and political con¯icts. Health, also, is often a product of culture and other social circumstances. Health may be promoted through non-health interventions or through more targeted health eorts seeking to eect behavior change. Preventive screening is of growing importance but such eorts often out-pace evidence of ecacy or cost-eectiveness. Many opportunities exist to build on new clinician±patient partnerships to make patients better informed and to eect positive health behavior. New technologies, and particularly the internet, oer new ways to promote health and more constructive illness behaviors. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Health promotion; Prevention; Social inequalities; Behavior change; Screening; Health status
1. Introduction This paper focuses on promoting health in memory of Sol Levine, a dear friend and close professional colleague for 35 years. This topic was chosen because his entire career was devoted in one way or another to understanding inequalities in health, factors eroding health status or interfering with eective provision of care and ways of enhancing health and the quality of life for all. In addition to being a formidable scholar, Sol had a special warmth and optimism that left a glow on all who came in contact with him. Our lives are less without him. Some biographical material can help put this presentation in context. In 1969 when I was Chair of the Medical Sociology Section of the American Sociological Association, I obtained a grant from the Carnegie Foundation for our section to explore various issues pertinent to impending national health insurance, which we all anticipated was around the
* Fax: +1-732-932-1253.
corner. I became chair of its steering committee for the next six years and Sol was a close collaborator. As was his wont, he became chair of our implementation committee and a co-editor with me of one our products, ``Issues in Promoting Health'', a supplement to Medical Care (Mechanic and Levine, 1977). If one goes back and examines the content of our work on the grant, it would seem that little has changed over the subsequent two decades. We divided our work into two main areas: organizational consequences of national programs and preventive health and health maintenance. In respect to the ®rst, we believed that eective evaluation required better ways of measuring outcomes and we organized a program on sociomedical indicators under the leadership of Jack Elinson. The other two committees dealing with organizations tackled issues of professional organization and control and the eects of medical organization and technology on humane care. As we proceeded we also had a group addressing the role of psychosocial factors in medical utilization. In the prevention/health maintenance area, we had a productive eort under the leadership of the late Marshall Becker on the modi®cation of
0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 8 ) 0 0 3 9 9 - 2
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health behavior. We had a group working on barriers to medical care among Chicanos and another group working on a conceptual basis for family medicine. The entire eort was directed not only at publication and dissemination in the usual way but also to stimulate interaction and discussion among social scientists, health professionals and policy-makers. Implementation was in Sol's good hands and we got a lot of `bang for the buck'. Looking back, it is clear that we had picked many of the key issues crucial to our health futures and ones that continue to be core issues for research and social policy. Among our concerns, and especially important to Sol, was getting a better understanding of the role of nonhealth factors on health levels. Monroe Lerner ably chaired this group and produced a stimulating analysis of broad determinants of health (Lerner, 1977). Some years later when Alvin Tarlov, who became an intimate friend and colleague of Sol's, became President of the Henry J. Kaiser Foundation, health promotion and disease prevention became the Foundation's key focus. In 1987 they organized an invitational conference under the leadership of John Bunker on Pathways to Health: The Role of Social Factors (Bunker et al., 1989) and both Sol and I presented papers and played an active role. The mission of the Foundation was close to Sol's heart and being and he left his many friends and colleagues behind in Boston and moved to California as Vice-President of the Foundation where he administered review of the programs in health promotion, functional outcomes and South Africa. From early in his career, Sol looked to broad population approaches to promote health and improved health care. In the early years of his career this was a less common perspective, although now health authorities throughout the world look to broad population approaches to limit morbidity and disability and contain future health care expenditures. Ocial eorts to examine health broadly began with the Canadian LaLonde report in the 1970's (LaLonde, 1974), followed by the American Surgeon General's report on health promotion and disease prevention later in the decade (US Assistant Secretary of Health and Surgeon General, 1979) and somewhat later the development and monitoring of national health objectives (US Public Health Service, 1991). These eorts are now common in many other countries, for example, in England's health of the nation objectives (Secretaries of State for Health, 1992) and in 1997 the Blair government appointed England's ®rst minister of public health.
2. National health objectives In the United States the year 2000 objectives resulted from the work of 22 expert working groups, the involvement of the health departments of varying states, almost 300 national organizations and some ten thousand participants (US Public Health Service, 1995). Their eorts led to 22 major general objectives in such areas as physical activity and ®tness, nutrition, maternal and infant health, violent and abusive behavior, unintentional injuries and so on. Within each area objectives were directed at achieving a certain level of health outcome, reduction of health risks and those relating to services and protection. Setting realistic objectives is a signi®cant ®rst step. Implementing these in any reasonable way requires sophisticated strategies and clear understanding of social, environmental and behavioral factors that aect how individuals behave and how the social system functions. Many eorts today are directed at increasing empowerment of deprived individuals and communities and initiatives to involve them in cooperative groups that share information, provide support and facilitate active coping and eective political advocacy. Such group mobilization has signi®cant potential. However, in a challenging analysis seeking to identify fundamental causes of disease, Link and Phelan (1995, p. 89) suggest that ``The resources that accrue to the more advantaged allow them to regain the health advantage that may have been dented temporarily by the intervention''. They argue that unless change is directed at fundamental social causes that underlie socioeconomic dierences, those with higher socioeconomic status are likely in a short time to acquire the relevant information and resources that are health enhancing, increasing socioeconomic disparities in health. While there is substantial understanding of the extent to which broad environmental and societal factors aect health, particularly socio-economic status and associated living conditions (Bunker et al., 1989), most activities in prevention and health promotion are typically focussed on individuals and small groups. Individual behavior of course is only part of the variance, but addressing broader and perhaps more fundamental factors involve signi®cant political con¯ict and competing economic, religious and cultural values and interests. There are occasional opportunities for addressing socio-economic inequalities and disadvantage and other macro in¯uences (Benzeval et al., 1995) but more often than not health professionals have to focus on the available opportunities. The typical windows of opportunity are to promote behavior conducive to health and improved access to appropriate and eective health and social services. Opportunities are also generally available to strengthen communities, increase peoples' involvement and participation,
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strengthen social support networks and increase the sense of personal empowerment, all related in one way or another with more positive health behavior and improved health outcomes. The bulk of national investments is expended on medical care services with the challenge to provide a mix of services that meet critical needs in a cost eective way and that promote better health. No-one anymore believes, as the architects of the British National Health Service did, that providing access to medical care would signi®cantly improve health to the point that patient demand and medical expenditures decrease. For all practical purposes public demand for care will always exceed what nations are willing to ®nance and in allocating care all systems must ®nd some reasonable balance between goals and levels of service. Costs will continue to increase to whatever level societies are willing to allow. Using the available resources wisely depends on eective targeting. There is considerable evidence that the uninsured population, which has been growing in the United States, has much less access to care and poorer health outcomes than those who are insured (Weissman and Epstein, 1994) and that there are many missed opportunities for prevention by more rational allocation of services. An important way policymakers in developed countries hope to contain growing health costs over the longer range is to promote health and more eective health behavior (Mechanic and Rochefort, 1996). Such eorts can be directed at the entire population, at the members of a particular health care plan, at members of de®ned risk groups who are targeted for intervention, or even at single individuals at risk. 3. Health promotion and culture Healthful behavior is a byproduct of ordinary everyday activities (Mechanic, 1995). Health behaviors that require continuing motivation, planning and consideration of costs and bene®ts tend to be unstable and easily disrupted. In contrast, when the behavior results as a consequence of following routines of everyday living it is more deeply entrenched and occurs instinctively. Healthful behavior is best culturally ingrained and built-in to patterns of work, family life and recreation. The problem is that changing culture is a formidable task. Health promotion at the population level can be speci®cally health directed or a product of broader nonhealth interventions that are seen as good on their own terms. Fluoridation of the water supply or immunization of the population are health speci®c interventions. In contrast general education, or more speci®cally eorts to teach children decision-making skills, may have important eects on health but are
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seen as good on their own terms. For example, it is believed that children who successfully learn decisionmaking skills are more astute and cope better in resisting peer pressure to smoke, to use drugs, or to participate in other unwanted behaviors (Clabby and Elias, 1986; Institute of Medicine, 1994). The beauty of such indirect in¯uences is that interventions are without additional cost since they would be carried out for other reasons. Education, for example, is a very powerful health promoting in¯uence (Mechanic, 1989). Individuals who are better educated not only know more, but they are more active in seeking information, better able to evaluate it, retain more of it and are more likely to use it as a basis for decisions and behavior (Feldman, 1966). 4. Behavior change Mass media health education initiatives are often ineective. The message may be poorly constructed and ineectively communicated. It may be too imprecisely focussed to gain attention or to be persuasive. It may lack credibility among those who are most at risk or be targeted entirely at the wrong groups. Some years ago I was a consultant to an eort of major foundations to design a health education series for public television that was to use entertainment programming (Maibach and Holtgrave, 1995) to get a health message across. Unfortunately, it was de®ned by the public as a health program and very few people watched it despite a large investment in trying to make the material audience-friendly and entertaining. People are often suspicious of direct eorts to change their behavior and may be more in¯uenced by information that comes incidently than through obvious in¯uence attempts. The credibility of such information is less likely to be challenged. By building such communications into ordinary programming, cost is very much reduced. A project at the Harvard School of Public Health has worked with television representatives to use designated drivers in drinking situations in entertainment programming (Montgomery, 1990). This is an indirect way to get an idea across to the general public and legitimize it at low cost. The project has been successful in having the idea adopted but its health impact is unknown. The larger issue, of course, is the extraordinary amount of negative health programming found in the media encouraging drinking, fast driving, smoking, risk-taking and violence. The cost-eectiveness of health promotion interventions are enhanced by targeting subgroups at high risk who are most likely to bene®t from intervention. Examples include AIDS education with IV drug users (Miller et al., 1990) or interventions with youngsters during the period of greatest vulnerability to initiating
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smoking (Evans, 1985). This can be undertaken within health plans or more generally in the community at large. The sponsorship of the intervention, of course, will determine whether it is solely directed to health insurance plan enrollees or a more diverse population. An increasingly common intervention involves the mobilization of varying types of support groups, selfhelp groups, survivor groups and the like. There is a great variety of groups taking on many functions. They vary from such well known approaches as Alcoholics Anonymous (AA) to psychoeducational groups for families of patients with chronic diseases. Such groups often provide social support, information, coping skills and an improved sense of mastery. Interacting with other people with comparable or even greater problems than one's own can reduce the sense of isolation, increase one's sense of community and support a variety of useful coping approaches. A recent randomized controlled study of a psychoeducational program for families of persons with schizophrenia found that the same intervention was more successful when administered in a group as compared with an individual setting (McFarlane et al., 1995). While group interventions may not always be ideal, the group process often provides support and reinforcement beyond the content of the intervention. The evidence for the impact of social support on health and coping is impressive but not all social support eorts are necessarily eective and some, however well intentioned, could be harmful (Thoits, 1995). A great deal depends on the structure of the group and group processes, the goals and content of group activity and how the individual relates to the group. Groups can scapegoat and intimidate as well as support, can reinforce dysfunctional behaviors and can isolate individuals from other constructive and normalizing in¯uences. For example, self-help groups called `Double-Trouble' groups are being organized around a 12-step program for individuals with co-morbid substance abuse and mental illness. Such persons when they join more traditional 12-step programs like Alcoholics Anonymous are discouraged from using medications, but such persons often decompensate with medication noncompliance. Double-trouble groups, in contrast, are intended to develop a dierent culture around medication issues. In recent years selfhelp groups organized around speci®c areas such as breast cancer, AIDS, mental illness and disability have become in¯uential in public policy as well as providing education and social support to their participants (Rodwin, 1994).
5. Preventive screening Another approach to health promotion are initiatives for early recognition of risk and disease prevention. A focus on prevention super®cially is an attractive answer. The common assumption is that prevention eorts must be cost-saving since preventing illness in the ®rst place avoids all the costs. This is often true at the individual level but commonly untrue in the aggregate, a point that even some sophisticated health professionals have diculty comprehending. In fact, only a few preventive eorts have been demonstrated to be cost-saving, although they may be cost-eective or clearly justi®able on other grounds (Russell, 1986). The potential to reduce expenditures through preventive eorts will depend on the prevalence of the illness, the costs and eectiveness of preventive interventions, the frequency with which the intervention has to be repeated or reinforced, the size of the population that can potentially bene®t, the capacity to target persons at highest risk and many other factors (Russell, 1986). The principle of large numbers is important here in that even a modestly priced intervention directed at a large population, most of whom are unlikely to develop a disorder, may be inordinately expensive in the aggregate or in terms of the cost for each disorder prevented. Preventive screening is an area of great public interest but one which often has uncertain value (Russell, 1994). The scienti®c potential for new screening tests for dierent types of cancer, genetic defects and other diseases is large, but too aggressive marketing of such technologies could be cost-ineective and even dangerous. One need look no further than the widespread use of the PSA test for screening for prostate cancer to see the potential dangers. While prostate speci®c antigen (PSA) screening is reasonably eective in detecting prostate cancers, the test yields a high rate of false positives (Mandelson et al., 1995). Large numbers of men with high PSA values then begin a trajectory of diagnostic procedures of increasing invasiveness. However, even detecting cancers is of uncertain value since many of these tumors would not progress within the lifespan of the individual and there is no evidence that intervention reduces mortality (Russell, 1994; Mandelson et al., 1995). Moreover, the interventions have many serious risks and adverse consequences. The PSA test is an impressive innovation and provides useful information and some argue that information is valuable even if interventions are not undertaken. What is typically not recognized is how awareness that one might have cancer threatens individuals and how the information itself, often supported by an aggressive urological surgeon, pushes people onto a trajectory of uncertain interventions. While the potential for repeated expenditures on PSA tests and
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other followup diagnostic procedures and interventions are very large, bene®ts are uncertain. PSA is clearly a promising screening approach that merits investigation on how it might best be used, but it has already become relatively routine. The story of PSA can be multiplied manyfold with other diagnostic procedures and interventions that have been widely applied before their value has been ascertained (Russell, 1994). As Black and Welch (1993) note in relation to new imaging technologies, ``...many patients may have been labeled with disease they do not really have and many have been given therapy they do not really need''. The future will bring seemingly amazing new preventive screening technologies well before we have the evaluations that allow us to assess their worth. We may be in the position of having these technologies diffuse almost universally, such as electronic fetal heart rate monitoring, only to discover later that the new technology not only provided no advantage but also involved increased risk (Shy et al., 1990). The growth of managed care should inhibit these tendencies to some degree, but changes are also needed in the culture of medicine and the expectations of patients. An unquali®ed faith in the value of technology makes it dicult to introduce a balanced perspective. 6. Developing a new clinician±patient partnership One component of creating a new medical culture is to involve patients more actively in decisions about their treatments (Mechanic, 1998). Wennberg and his colleagues, for example, have developed impressive videotape materials for helping patients make intervention choices in such conditions as breast cancer and benign hypertrophy of the prostate (BHP). In these programs patients watch videotapes of thoughtful patients who faced a similar choice explain their reasoning in the selections they made. When presented with such options patients commonly prefer more conservative options than doctors (Wennberg, 1990). While such programs have great promise, they also present diculties. Patients are often excessively fearful of invasive interventions and are easily dissuaded from them. At times, something more than a neutral medical opinion is needed to overcome resistance to treatments that can be of signi®cant bene®t. Patients' preferences, of course, should determine the risks taken, but decision-making programs must be exceedingly careful in how they present options and choices. A related problem is the dynamic character of medical understanding and biomedical research. For example, the Wennberg materials on BHP are impressively done and both the presentations for the `watchful waiting' option and for surgery are persuasively and fairly presented. Maintaining a balanced objective view
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in the development of such materials, however, is exceedingly dicult, time-consuming and costly. Soon after the Wennberg videotapes became available the ®rst randomized controlled trial ever done, comparing surgery to watchful waiting among men with moderate symptoms, was reported in the New England Journal of Medicine (Wasson et al., 1995). The study found signi®cant symptom relief in the surgical group compared with watchful waiting and no greater serious adverse eects than in the watchful waiting group. This study suggests the possibility that some of the adverse eects typically attributed to surgery in clinical studies, such as impotence and incontinence, may be associated with the condition in some way and not with surgical intervention. A larger number of cases will be required to assess such issues de®nitively, but, in any case, these new results change the decision calculus. Developing tapes for important treatment decisions and keeping them up-to-date is a major enterprise. Since various groups have a ®nancial interest in treatment decisions, they often have dierent perspectives on the decision. Thus, treatment tapes might be produced by medical industries, drug companies, specialty organizations, etc. Some system is needed to review such treatment aids and accredit them if the public is not to become confused and misled. Moreover, once produced, there has to be an eective distribution system for these resources. In short, carrying forward on such innovations require careful eorts and considerable ®nancial resources. The ready availability of computers and improved interactive computer software oer many opportunities for health plans to help patients assess health risks, promote health in various areas and teach self-management skills relevant to various problems and diseases. Such instructional programs are also used in preparing patients for various procedures or in postsurgical instruction. Computers cannot ever fully replace interpersonal communication or opportunities to give information and receive speci®c feedback on the patient's unique experiences. Patients prefer interpersonal contact and are generally more in¯uenced by it than impersonal forms of communication. Good computer software, however, can help clinicians gather systematic information from patients and provide much general information to patients. Some of the time saved could be invested in personal followup to insure that patients' concerns have been addressed and to provide necessary feedback and reassurance. One innovative use of such technology and the internet is the Comprehensive Health Enhancement Support System (CHESS) developed by the Center for Health Systems Research and Analysis at the University of Wisconsin-Madison (Gustafson et al., 1993, 1994). This educational and supportive program now has modules for patients with AIDS, breast can-
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cer and other serious health programs as well as modules for family members of patients with Alzheimer's disease and alcoholism. A personal computer is placed in the home and the program oers eleven services including answers to frequently asked questions, articles and other informational resources, electronic access to relevant discussion and support groups, opportunities to ask questions to an expert via e-mail, decision aids, personal accounts of others with similar problems, etc. A major issue with any such program is the quality of the programming, its scienti®c credibility and its ®delity to the existing state of knowledge. CHESS and related approaches are still in a very early stage of development and there is much yet to be worked out. However, CHESS has been studied in randomized trials and has been shown to have high acceptability and use, to be accessible to persons with little education and minority status and to improve patients' participation in treatment and quality of life (Thorson, 1994; Peressin, 1995; Pingree et al., 1996; Center for Health Systems Research and Analysis, 1997). CHESS illustrates the enormous potential for using carefully screened information and decision aids and access to support groups as a way of contributing signi®cantly to a more involved and better informed patient.
7. Taking account of arational aspects of care Much of the eort to educate the public and change public and patient behavior is based on an implicit assumption of behavioral rationality. This isn't a bad assumption because people are substantially rational but it is important to be aware of the limitations of this viewpoint. Consider the extremely robust and persistent assumption that if incentives are provided to make people aware of the costs of their medical care, they will use care more judiciously and will primarily use care when it is appropriate and eective. Yet investigators repeatedly ®nd that ®nancial barriers to care reduce utilization but in an unselective fashion. Ecacious care is reduced as much as trivial services. For example, the RAND Health Insurance Experiment found that coinsurance was an eective barrier to utilization, but there was little dierentiation in its eects between useful and inappropriate care (Newhouse and the Insurance Experiment Group, 1993). Public health workers also have long known that providing health services free and making them accessible doesn't necessarily lead to their use in all populations. There is now a rich literature on illness behavior that examines the illness schemas people use and how they make sense of their internal experiences (McHugh and Vallis, 1986; Benyamini and Leventhal, 1997).
What may seem rational to an outside observer may have little relevance within the context of the individual's meaning systems and explanatory schemes. Any serious examination of utilization must be sensitive to the latent functions of medical care where people visit doctors to gain reassurance, to legitimate release from usual responsibilities, to account for failures to meet family and work obligations, to gain access to certain privileges or achieve other types of secondary gain (Mechanic, 1978). Much help-seeking is security based, but such concerns are typically neglected in making sense of utilization. Often the policy debate becomes very distant from reality. For example, some managed care organizations refuse to pay for emergency care visits if after the fact the problem turns out not to have been an emergency. However, the whole point of seeking emergency care in many instances is to obtain an informed assessment of symptoms that are frightening and worrisome. Even if the compromise that symptoms are an emergency if a `reasonable person' would have believed them to be so fails to take account of the large variations in people's fears and anxieties, cultural orientations, knowledge and understanding and coping capacities under stress.
8. The preventive potential of therapeutic relationships The clinician±patient relationship remains a source of signi®cant in¯uence and opportunity to promote improved health (Mechanic, 1998). Even short inquiries and discussions with patients about smoking can result in an increased cessation rate of about 5% (Russell et al., 1987). This may seem unimpressive, but it is one of the most eective uses of clinician time given the destructive consequences of smoking. It isn't that patients aren't aware that smoking is injurious to health, but the credibility and in¯uence of one's own physician and the discussion in the context of one's own health, can have a powerful impact. The clinical situation can also be a powerful context for teaching patients selfcare and self reliance. For example, one health plan instructed mothers on how to take throat cultures when their children had sore throats. The culture materials were given to the mothers and they could drop o the cultures at the clinic at their convenience rather than schedule a doctor or nurse appointment. Mothers liked this arrangement and an evaluation showed that they carried out the procedure in a satisfactory way (Katz and Clancy, 1974). Health programs are increasingly teaching patients to monitor their blood pressure, blood sugar and other health signs and increasingly sophisticated technologies make this easier.
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9. Conclusions In summary, there are many levels of promoting health, preventing disease and minimizing disability. In recent years there has been a resurgence of interest in the role of social inequalities in health outcomes and the role of socioeconomic variables. Studies increasingly report that inequalities net of economic status are associated with poor health (Kawachi and Kennedy, 1997) and at the individual level the importance of social support networks and sense of control is persistently demonstrated (Marmot et al., 1995). Sol Levine was particularly intrigued by these relationships and the possibilities they implied and was instrumental in setting up the Joint Program in Society and Health between the Harvard School of Public Health and the New England Medical Center and in encouraging young investigators who are now making major contributions to this ®eld. We still have much to learn about the complex interdependencies among these predictors but work is going forward at a more rapid pace because of Sol's eorts and encouragement (Amick et al., 1995). There are, of course, increasing opportunities in primary prevention through improved health understanding and increased healthful behavior, some preventive screening approaches that bring high bene®ts relative to cost and more sensitive and sophisticated use of clinician±patient relationships as tools to achieve greater health understanding and better health status. The struggle to prevent disease and improve health is a continuing one because health exists in the cultural context of people's values and aspirations and these are always changing in adapting to new environments. Eective public health and medicine, however, can make it more possible for all of us to ful®ll our goals and to achieve a high level of function and quality of life.
Acknowledgements Supported, in part, by a Robert Wood Johnson Foundation Health Policy Investigator Award.
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